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Acute care Flashcards

1
Q

what are side effects of ondansetron?

A 
Diarrhea-self limiting, lasts 48h
drowsiness - rare
extrapyramidal reaction
hallucionation
sz
neuroleptic malignant syndrome
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2
Q

what the mechanism of action of ondansetron?

A

selective serotonin 5-HT3 receptor antagonist!

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3
Q

what are ondansetron doses

A

8-15 kg - 2mg
15-30kg - 4 mg
> 30 kg - 6-8 mg
ORT 15-30 min post

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4
Q

In complicated pneumonias, how often do we have a positive blood culture?

A

10%

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5
Q

What is the Abx choice for complicated pneumonia?

A

Cefotaximeor ceftriaxone +/- Clinda for anaerobic or MRSA

can switch from Clinda to Vanco in culture proven or stongly suspected MRSA pneumonia

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6
Q

How long do complicated pneumonia + effusion require Abx for?

A

3-4 weeks

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7
Q

When do you switch from IV to PO Abx in complicated pneumonia

A

Drainage is complete
clinical improvement
OFF O2

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8
Q

when switching from IV to PO Abx in complicated pneumonia, what Abx d you choose?

A

Amoxiclav

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9
Q

What are surgical options for complicated pneumonia?

A

VATS
Early thoracotomy
Chest tube + fibrinolytics-most cost effective, get out of hospital faster

t-PA at 4 mg in 50 ml of NS for up to 3d

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10
Q

Do you need a repeat CXR post complicated pneumonia+discharge?

A

yes at 2-3 month

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11
Q

why are children more likely to develop intracranial lesions from head trauma

A

larger head to body ratio
thinner cranial bone
less myelinated

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12
Q

what are the most common causes for head trauma in canada?

A 
falls
sports related
direct hit or colliding
Bicycle related
MVA/pedestrian
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13
Q

Clinical features associated with intracranial injury (4)

A

prolonged LOC
confusion
worsening HA
persistent vomiting

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14
Q

How do you classify head trauma based on GCS?

A

14-15 - mild
9-13 -mod
<=8 - severe

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15
Q

Which patients with a GCS of 14-15 require a CT brain?

A

if abnormal mental status or
abnormal neuro exam or
suspect skull fracture

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16
Q

which patients require a skull xray?

A

if LESS than 2 yrs + boggy hematoma

or if concerned about abuse

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17
Q

What is the CATCH rule for minor HI?

A

a child with a minor head injury (witnessed LOC, amnesia disorientation, >1 emesis, irritable) needs a head CT is has >=1:

A) High risk-Nsx: WIGS

  • GCS < 15 at 2 hours
  • suspect open or depressed skull fractures
  • Hx of worsening HA
  • irritability on exam if kid less than 2

B) medium: SDH

  • signs of basal skull#
  • large boggy hematoma if > 2yrs
  • dangerous mechanism
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18
Q

What factors increase the risk of post-traumatic Sz

A 
young age
severe head trauma GCS<8
cerebral edema
subdural hematoma
open or depressed skull fracture
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19
Q

what is the mgnt option for a pt with impact sx or soon after, with normal neuro exam and imaging?

A

can discharge home if all normal

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20
Q

what are indicators of poor prognosis for intracranial injury?

A 
severity at initial presentation
Inc ICP
severity of other injuries
ADHD
SES
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21
Q

who should get a skull xray?

A

if < 2 yrs and boggy hematoma
if depressed skull fracture - CT preferred
if penetrating lesion -CT preferred

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22
Q

What are the 2 absolute indications for head CT

A
  1. focal neuro deficit

2. suspected open or depressed skull fracture or widened or overlaping skull # on xray

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23
Q

what are relative indications for CT not in CATCH rule

A

known coagulation disorder

GCS < 14 at any point

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24
Q

when do we observe pt post minor head trauma

A

if at initial evaluation:

  • severe or persistent HA
  • Repeated vomiting
  • Hx of LOC
  • Amnesia
  • Confusion
  • Lethargy or irritability
  • immediate post traumatic seizure

***need to be observed for 4-6 hours

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25
what is the prevalence of asthma in canada
11-16%
26
What are ED management objectives for Asthma
1. assess severity 2. Rx to decrease resp distress and improve oxygenation 3. appropriate disposition pst Rx 4. arrange proper FU
27
a sat < 92 % at presentation is associated with what outcome?
higher morbidity | greater risk of hospitalization
28
when should an asthmatic get a CXR
suspect pneumothorax ? pneumonia ? FB if fail to improve with max treatment
29
when should an asthmatic get a gas done?
if no improvement on max therapy
30
what is the suggested O2 sat in context of asthma?
>= 94%
31
What should be the initial mgnt steps for asthma?
1. treat hypoxemia 2. give short acting beta 2 agonist - MDI+spacer unless impending resp failure 3. Steroids 4. assess response 5. consider other treatments
32
What are Ventolin SE
tachycardia - no known arrhythmia in kids but in adult, need to be on monitor Low K Hyperglycemia
33
when should Atrovent be used with caution?
kids with soy allergy
34
what is the dose of MgSO4
25-50 mg/kg over 20 min (max 2g)
35
what category of drugs id Ipratropium?
anticholinergic
36
why is Atrovent useful
Used as an add on 1. reduced hospital admission rates AND 2. better lung function when used with Ventolin during first hour
37
what can steroids do for asthma
1. reduce need for admission 2. decrease risk of relapse after initial treatment 3. earlier DC
38
what can MgSO4 do for astham
1. improves resp function | 2. decreases hospital admission
39
when should you use MgSO4?
incomplete response during first 1-2 hours in pt with moderate and severe asthma
40
IV salbutamol will help asthma how?
improve pulmonary function and gas exchange
41
What are treatment options for children with asthma who failed to improve on continuous salbutamol and IV steroids
1. Aminophylline IV 2. Heliox 3. I & V
42
what are the complications of mech ventilation for an asthma patient?
26% will have complication - pneumothorax - impaired venous return - cardiovascular collapse from inc intrathoracic pressure - death
43
what are reasons to admit an asthmatic
1. need for O2 2. Deterioration while on steroid 3. persistent increase WOB 4. Needing salbutamol more than q4 after 4-8 hours of treatement
44
What are DC criteria from the ED for asthmatics
sats > 94% on RA need ventolin less often than q 4 minimal or no resp effort improved air entry
45
what is the discharge home plan for an asthmatic
``` complete 3-5 d PO steroid ventolin until exacerbation over asthma action plan review technique encourage FU with GP ```
46
what inhaled steroid can a 3 month old use and a 12 month old?
3 month - pulmicort nebs | 12 month - flovent
47
at what age can we start ciclesonide
Alvesco | 6 yrs
48
what is the mortality associated with status epilepticus
2.7-8%
49
what acute causes of status epilepticus
1. CNS infection 2. AED non compliance or withdrawl 3. AED overdose 4. Other drug overdose 5. metabolic disturbances - high/low glucose, low Na, Low Ca, anoxic injury
50
what are remote causes of status epilepticus?
cerebral migrational disorders- lissencephaly cerebral dysgenesis HIE progressive neurodegenerative
51
if pt arrives in presumed status, what are important Hx info needed
1. Hx of seizures 2. associated symptoms - fever... 3. medications used 4. Allergies
52
patient in status is found to have BG 2.5, what is the mgnt?
1. IV access 2. Bolus with: 5 ml/kg of D10 or 2ml/kg of D25 3. recheck BG at 3-5 min 4. if low again - re-bolus
53
what is the Sz termination rate if anticonvulsants are used within 20 min?
70-85%
54
if no IV access, what is the first line Rx for seizures
Buccal midazolam is better
55
if IV access, what is the first line Rx for Sz
IV lorazepam - longer acting and less resp depression compared to diazepam
56
what are second line Rx for seizures
IV phosphenytoin and phenytoin | if no IV - IM fosphenytoin or IO phenytoin
57
what are SE of phosphenytoin and phenytoin?
arrythmia bradycardia low BP
58
what can happen if phenytoin is improperly given - IV interstitial
purple glove syndrome: edema, discoloration, pain distal to site
59
when is phenobarbital used?
second line neonatal Sz pt already on phenytoin maintenance
60
what are SE of phenobarbital?
sedation resp depression hypotension
61
when would you use pyrodoxine to treat sz
if thinking it is a metabolic disorder | may be pyridoxine dep epilepsy
62
what is the MC cause for status
prolonged febrile Sz
63
when is status considered refractory?
if 2 different drugs used
64
What are the drug options for refractory status?
``` I&V 1. continuous midazolam infusion: fast acting and with short half life bolus+mainenance max 24 microg/kg/min SE: low BP ``` 2. thiopental: can be added to phenytoin only - so may need to stop other stuff stay on it for 48 hrs before wean as restart phenobar 3. propofol/topiramate/levetiracetam
65
if patient with no know allergies, presents to the ED with ? anaphylaxis, What criteria are need to make this Dx
1. acute onset with skin and/or mucosal tiusse and >1: - resp compromise - reduced BP or other end organ dysfunctions
66
if a pt is exposed to a likely allergen, what features are needed to make the Dx of anaphylaxis?
post exposure + >=2: - skin/mucosal involvement - resp compromise - reduced BP or signs of end organ - persistent GI symptoms (pain/V)
67
if a patient is know to be severely allergic and presents post exposure, what features are needed to Dx anaphylaxis?
1. Reduced BP
68
what are epi pen doses?
Epipen Jr - 0.15 mg for 10 to 25 kg Epipen - 0.3 mg for >25 kg Twinject of either dose and provides
69
how do you give epi for anaphylaxis
0.01 mg /kg of 1:1000 IM every 5 to 15 min
70
what are second line antihistamines used in anaphylaxis?
H1 antagonist - NO effect on resp/GI/Cardio. ONLY for cutaneous symptoms ( Cetirizine PO) H2 antagonist - in combo works better. Ranitidine PO or IV 1mg/kg
71
What are the steroid choices for anaphylaxis
not totally provent to help but used, no effect acutely - moderate - PO pred - severe - IV methylpred
72
when can the biphasic reaction occur?
between 1- 72 hours | most often in first 4-6 hours
73
What is needed for a child to meet Dx of minor head injury
need one of these to use CATCH criteria: 1. definite amnesia 2. witnessed LOC 3. witnessed disorientation 4. persistent vomiting 5. if less than 2 - irritable
74
how does epi effect a, B1/B2
alpha 1 - A for arteries B1 - one heart B2 - 2 lungs
75
why is fosphenytoin better?
less resp depression runs faster over 5 min can be run in with D5 and therefore don't need IV less risk of purple glove
76
who should receive ondansetron?
mild to mod dehydration 6 mo to 12 yrs who failed oral rehydration

CPS (10 decks)

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